Definition: Myringoplasty is a procedure
used to seal a perforated tympanic membrane using a graft
material. Formerly an operating microscope was used to perform
myringoplasties. Recently with the common usage of nasal
endoscope for nasal surgeries, we have started using it for ear
surgeries also.

The aim of this article is to share our
experiences on endoscopic myringoplasty. Endoscopic
myringoplasty is performed using a 0 degree rigid endoscope.
In fact we use the 4 mm nasal endoscope itself for this
purpose. This procedure is always performed
transcanally.

Procedure:
The surgery is performed under local anesthesia. Temporalis
fascia graft is harvested under local anesthesia conventionally and
allowed to dry. The external auditory canal is then
anesthetised using 2 % xylocaine mixed with 1 in
10,000 adrenaline injection. About 1/2 cc is infiltrated at 3
- o clock, 6 - o clock, 9 - o clock, and 12 - o clock positions
about 3mm from the annulus. The patient is premedicated
with intramuscular injections of 1 ampule fortwin and 1 ampule
phenergan.

Step I:
Freshening the margins of perforation - In this step the margins of
the perforation is freshened using a sickle knife of an
angled pick. This step is very important because it breaks the
adhesions formed between the squamous margin of the ear
drum (outer layer) with that of the middle ear mucosa. These
adhesions if left undisturbed will hinder the take up of the neo
tympanic graft. This procedure will infact widen the already
present perforation. There is nothing to be alarmed about
it.

Step II: This step is
otherwise known as elevation of tympano meatal flap. Using a
drum knife a curvilinear incision is made about 3 mm lateral to the
annulus. This incision ideally extends between the 12 - o
clock, 3 - o clock, and 6 - o clock positions in the left ear, and
12 - o clock, 9 - o clock and 6 - o clock positions in the right
ear. The skin is slowly elevated away from the bone of the
external canal. Pressure should be applied to the bone while
elevation. This serves two purposes:1. It prevents
excessive bleeding2. It prevents tearing of the flapThis
step ends when the skin flap is raised up to the level of
the annulus.

Step III:
Elevation of the annulus and incising the middle ear
mucosa. In this step the annulus is gradually lifted from its
rim. As soon as the annulus is elevated a sickle knife is used
to incise the middle ear mucosal attachement with the tympano meatal
flap. This is a very important step because the inner layer
of the remnant ear drum is continuous with the middle ear
mucosa. As soon as the middle ear mucosa is raised, the flap
is pushed anteriorly till the handle of the malleus becomes
visible.

Step IV: Freeing the
tympano meatal flap from the handle of malleus. In
this step the tymano meatal flap is freed from the handle of
malleus by sharp dissection of the middle ear mucosa.
Sometimes the handle of the malleus may be turned inwards
hitching against the promontory. In this scenario, an
attempt is made to lateralise the handle of the
malleus. If it is not possible to lateralise the handle of the
malleus, the small deviated tip portion of the handle can be
clipped. The handle of the malleus is freshened and
stripped of its mucosal covering.

Step V: Placement of graft
(underlay technique). Now a properly dried temporalis fascia
graft of appropriate size is introduced through the ear canal.
The graft is gently pushed under the tympano meatal flap which has
been elevated. The graft is insinuated under the handle of
malleus. The tympano meatal flap is repositioned in such a way
that it covers the free edge of the graft which has been
introduced. Bits of gelfoam is placed around the edges of the
raised flap. One gel foam bit is placed over the sealed
perforation. This gelfoam has a specific role to
play. Due to the suction effect created it pulls the graft
against the edges of the perforation thus perventing
medialisation of the graft material.

The following advantages
were noted in this procedure:

1. The quality of image
was excellent.2. Documentation of the procedure became
simple3. The middle ear can be easily examined using an
endoscope4. Almost all cases may be performed transcanally
avoiding unnecessary post aural incision and
suture.

Disadvantages:

The only disadvantage noted by
this author was that both the hands were not free. One
hand must be utilised to stabilise the endoscope.

When
compared with conventional microscopic myringoplasy, the author
found no difference in the success rates. Added to this is the
convenience and portability of the endoscope.

The
surgical clipping shown here has been recorded while doing
endoscopic myringoplasty.